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after accident, and it may be noted that although the ankle jerks returned earlier, the
intensity of reflex response became more marked in the knee jerks once these returned.
Moreover, while at first the flexion synergy of the lower limbs was predominant, it
gradually diminished and was replaced by the prevalent extension synergy.
Case 2.
Another example is a young soldier aged 19, who sustained a complete tetraplegia
below Cy as the result of a fracture dislocation of C6 following diving into shallow water.
He was seen on the day of injury on 13 August 1944 by a neurologist who reported
complete paralysis below C8 of flaccid type with areflexia including the triceps jerk. There
was, however, a plantar flexion response to plantar stimulation on both sides. There was
also priapism. On admission to Stoke Mandeville one day later, he had a bilateral
Horner's syndrome, marked vasodilatation in face and neck with obstruction of the naso-
pharyngeal passages, paralysis of both triceps and of all finger and hand muscles with
the exception of the extensors of the wrist and the radial portion of the extensor digitorum
on the left. There was complete sensory loss below C8 but also marked sensory impair
ment in Cy. The pattern of reflex return in this case is shown in Table 6, which also
shows a gradual reflex recovery in the cephalad direction. At the end of October 1944 a
marked increase of the reflexogenic zone over the whole paralysed area of the body was
noted. Plantar stimulation on either side not only set up marked flexion synergy of the
ipsilateral paralysed leg but also resulted in contraction of the ipsilateral trunk and
abdominal muscles and marked response of the paralysed extensors of all fingers and
thumb on the same side. This extensive reflex response of the fingers and thumb on
stroking the sole of the left foot could be elicited bilaterally (Fig. 106) but only ipsilater-
ally on stroking the right sole. In due course, this exaggerated reflex response gradually
diminished in intensity but was still elicitable. Moreover, the profound flexion synergy
of the lower limbs gradually decreased and in the middle of 1946 was replaced by a
prevalent extensor synergy.
In contrast to this group of patients with early return of the ankle jerks, there are
other complete transverse lesions where the return of the tendon reflexes nearer to the
transection, such as the knee jerk, may precede that of the ankle jerk, as shown in the
following example.
Case
5. A soldier aged 20 sustained a complete transverse lesion below T8 with a right
haemo-pneumothorax as a result of a gunshot injury on 25 June 1944. On admission to
Stoke Mandeville 11 days after injury, he showed flaccid paralysis of both lower limbs
with a complete sensory loss below T8 and loss of control of bladder and bowels. The
pattern of reflex return is shown in Table 7. While in this case the extensor response of the
big toe to plantar stimulation appeared much earlier than either knee or ankle jerk, the
knee jerks returned before the ankle jerks and it may be noted that there was not only a
definite delay in the return of the right ankle jerk but the intensity of the withdrawal
response was also less marked on the right side indicating a difference in the intensity
of the spinal shock between the two halves of the spinal cord below the level of the lesion.
Case 4.
A further case in this group is a soldier aged 19, who sustained a gunshot injury
to the yth cervical vertebra resulting in a complete transverse lesion below Ti/2. He was
